WALLINGFORD, Conn. — UPDATE: In a statement on Thursday, Dec. 5, the state comptroller said that Anthem would no longer cap anesthesia for Connecticut patients.
Anthem insurance has announced changes to coverage that has many physicians up in arms.
On Nov. 14, the American Society of Anesthesiologists put out a letter that sounded the alarm that the Connecticut-based insurance company suddenly decided to cap its coverage of anesthesia at an arbitrary time limit. After that limit is reached, customers would have to pay out of pocket for the remaining anesthesia.
The change will affect Anthem customers in Connecticut, New York, and Missouri and doctors say it isn’t based on good medicine.
“There shouldn’t be an arbitrary cutoff,” said Connecticut Anesthesiologist Dr. Kenneth Stone.
“They are prioritizing their profits over medical care,” added Dr. Jonathan Gal of the American Society of Anesthesiologists.
The doctors agree that Anthem’s recent edict that it will only pay for anesthesia up to a time limit is not only dangerous, but heartless.
RELATED: Anthem insurance isn’t being straightforward about rate changes for special needs therapies
“We have the patient's interest in mind. It would be nice if Anthem had the same perspective,” remarked Stone.
Doctors won’t be waking patients up to ask them permission to continue medically necessary anesthesia, but that means when they do wake up, they may be whacked with an unexpected out-of-pocket expense.
“There are circumstances where they won’t pay for any of the anesthesia even up to the point of where they say it’s justified. It’s just absurd,” said Stone.
FOX61 met Stone at St. Mary’s Hospital in Waterbury. He’s the calming last face a patient sees before they fall asleep. He points out that the stress and nerves surrounding surgery don’t need to be compounded by a crippling financial uncertainty.
“When a patient needs surgery, it’s a scary time for them. There is no minor surgery from the perspective of a patient,” said Stone.
Doctors cite real-world examples of surgeries taking longer than expected for reasons such as blood loss, difficult anatomy, a complication or comorbidity. Doctors say medicine isn’t one size fits all.
“In the moment, do no harm. We all took the Hippocratic oath,” noted Gal.
The American Society of Anesthesiologists has called on Anthem to immediately reverse the rule. FOX61 asked Anthem to make an executive available for an interview. It didn’t.
But it did send a statement that said in part, “...we identified additional ways to safeguard against potential anesthesia provider overbilling.”
Anthem went on to say it is using the Center for Medicaid Services, “Physician Work Time values to determine the appropriate number of minutes...”
It continued that providers who go beyond the time limit can, “submit documentation for further review,” as part of a claim dispute.
This is just the latest policy change from Anthem. In October, FOX61 was the first station to uncover and investigate rate cuts on speech, feeding and other therapies for people with special needs. Now, the multi-billion-dollar Connecticut-based insurance giant is accused of making a unilateral profit-driven decision for people who need surgery.
When FOX61 investigated Anthem in October, our report shined a light on the impact rate cuts had on special needs therapies. That’s when state lawmakers started paying attention.
“My concern is that some patients may decide to delay or not do these types of surgeries and procedures out of concern for what those bills might be,” remarked Republican state Sen. Jeff Gordon.
Not only is Gordon a lawmaker, he’s also a physician. Now, he’s vowing to craft bipartisan legislation to put guardrails of accountability on Anthem.
“If these insurances have the light shined on them so it’s a more transparent process, you’ll certainly hear from the medical community advocating for patient care, but you’ll also hear from the public who will be concerned about this. And that is a legitimate role of the state, I believe, for oversight,” explained Gordon.
Anthem claims the policy move is an effort to make healthcare simpler and more affordable. It claims it won’t apply to anesthesia providers in Connecticut, for now. Nor would the policy apply to maternity or pediatric services.
The change goes into effect in February of the new year.
Anthem’s full statement is as follows:
“Anthem strives to help make health care simpler and more affordable. One of the ways to achieve that goal is to help ensure that claims are accurately coded, and providers are reimbursed appropriately for the services they provide to members. Improper coding drives healthcare costs higher than they otherwise would be.
Through our continuous efforts to improve affordability and accessibility to care, we identified additional ways to safeguard against potential anesthesia provider overbilling.
As a result, effective Feb. 1, 2025, we are putting safeguards and validation processes in place for how we evaluate billed time on claims for anesthesia services, using the CMS Physician Work Time values to determine the appropriate number of minutes. Note: The policy is being rolled out in several states; however, at this time, the policy will not apply to anesthesia providers in Connecticut.
This update is consistent with industry standard coding requirements and the anesthesia formula set by the American Society of Anesthesiologists.
For procedures requiring more time than set or recommended by these standards, providers will be able to submit documentation for further review, as outlined in our claim dispute process.
At this time, Maternity and Pediatric services are excluded from this update due to the varying nature of their care delivery. We will continue to monitor utilization of anesthesia services for these populations.”
The American Society of Anesthesiologists full statement is as follows:
“In an unprecedented move, Anthem Blue Cross Blue Shield plans representing Connecticut, New York and Missouri have unilaterally declared it will no longer pay for anesthesia care if the surgery or procedure goes beyond an arbitrary time limit, regardless of how long the surgical procedure takes. The American Society of Anesthesiologists calls on Anthem to reverse this proposal immediately.
Anesthesiologists provide individualized care to every patient, carefully assessing the patient’s health prior to the surgery, looking at existing diseases and medical conditions to determine the resources and medical expertise needed, attending to the patient during the entire procedure, resolving unexpected complications that may arise and/or extend the duration of the surgery, and working to ensure that the patient is comfortable during recovery.
Payment for anesthesia services is based on several factors, including the exact amount of time for anesthesiologists to deliver care preoperatively, during the operation, and when transitioning the patient to the recovery unit afterwards. With this new policy, Anthem will arbitrarily pre-determine the time allowed for anesthesia care during a surgery or procedure. If an anesthesiologist submits a bill where the actual time of care is longer than Anthem's limit, Anthem will deny payment for the anesthesiologist’s care. With this new policy, Anthem will not pay anesthesiologists for delivering safe and effective anesthesia care to patients who may need extra attention because their surgery is difficult, unusual or because a complication arises.
“This is just the latest in a long line of appalling behavior by commercial health insurers looking to drive their profits up at the expense of patients and physicians providing essential care,” said Donald E. Arnold, M.D., FACHE, FASA. “It’s a cynical money grab by Anthem, designed to take advantage of the commitment anesthesiologists make thousands of times each day to provide their patients with expert, complete and safe anesthesia care. This egregious policy breaks the trust between Anthem and its policyholders who expect their health insurer to pay physicians for the entirety of the care they need.”
ASA urges people concerned about Anthem’s proposal to contact their state insurance commissioner or their state legislator.
In June 2024, Elevance Health, the corporate name for Anthem, reported a 24.12% increase in its year-over-year net income to $2.3 billion and a 24.29% increase in its year-over-year net profit margin.”
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Matt Caron is a reporter at FOX61 News. He can be reached at mcaron@fox61.com. Follow him on Facebook, X and Instagram.
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